Basic Information
| Provider Information | |||||||||
| NPI: | 1124141460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENGO | ||||||||
| FirstName: | NYAWOH | ||||||||
| MiddleName: | WINNIFRED | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JENGO | ||||||||
| OtherFirstName: | NYAWOH | ||||||||
| OtherMiddleName: | WINNIFRED | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2127 S 58TH ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191435907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157273578 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2100 W GIRARD AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191301400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156850800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | TE007796 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.